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Chapter 34
Women’s Health Drugs
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Female Reproductive Functions

Female sex steroid hormones



Estrogens
Progestins
Pituitary gonadotropin hormones


Follicle-stimulating hormone (FSH)
Luteinizing hormone (LH)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2
Female Reproductive
Functions (cont’d)

Female sex steroid hormones and pituitary
gonadotropin hormones promote:

Development of primary and secondary sex
characteristics
 Start of menses and regulation of menstrual cycle
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3
Estrogens

Three major endogenous estrogens





Estradiol (principal and most active)
Estrone
Estriol
Synthesized from cholesterol in ovarian follicles
Basic chemical structure of a steroid
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
4
Exogenous Estrogenic Drugs–
Synthetic

Steroidal


Conjugated estrogens, estradiol transdermal,
estropipate, many others
Nonsteroidal


Diethylstilbestrol
No longer available in the United States
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5
Estrogens (cont’d)

Responsible for:

Development and maintenance of the female
reproductive system
 Development of female secondary sex characteristics
 Shaping of body contours and development of the
skeleton
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6
Estrogens: Indications

Treatment or prevention of disorders that result
from estrogen deficiency

Atrophic vaginitis
 Hypogonadism
 Oral contraception (given with a progestin)
 Uterine bleeding
 Vasomotor spasms of menopause (“hot flashes”)
 Osteoporosis
 Breast or prostate cancer
 Ovarian failure or castration
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7
Estrogens: Contraindications




Any estrogen-dependent cancer
Undiagnosed abnormal vaginal bleeding
Pregnancy
Active thromboembolic disorder or history
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8
Estrogens: Adverse Effects





Thrombolytic events—most serious
Nausea—most common
Hypertension, thrombophlebitis, edema
Vomiting, diarrhea, constipation, abdominal pain
May cause photosensitivity, chloasma
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9
Estrogens:
Adverse Effects (cont’d)



Amenorrhea, breakthrough uterine bleeding
Tender breasts, fluid retention, headaches
Others
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10
Estrogens and HRT: The North
American Menopause Society
(NAMS) 2010



Supports initiating HT (hormonal therapy)
around the time of menopause to treat
menopause-related symptoms and to treat or
reduce the risk of certain disorders (e.g.,
osteoporosis, fractures)
Hormone replacement is not recommended for
women with histories of endometrial cancer
In women with breast cancer, estrogen therapy
has not been proven safe and might raise
recurrence risk
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11
Continuous Combined Hormone
Replacement Therapy


Use of estrogen therapy alone has been
associated with an increased risk of endometrial
hyperplasia, a possible precursor of endometrial
cancer
Addition of continuously administered progestin
to an estrogen regimen reduces the incidence of
endometrial hyperplasia associated with
unopposed estrogen therapy
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12
Progestins

Synthetic derivatives of progesterone

hydroxyprogesterone (Hylutin)
 levonorgestrel (Plan B)
 medroxyprogesterone (Provera, Depo-Provera)
 megestrol (Megace)
 norethindrone acetate (Aygestin)
 norgestrel (Ovrette, Ovral)
 progesterone (Prometrium)
 etonogestrel implant (Implanon)
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13
Progestins: Indications

Treatment of functional uterine bleeding caused
by:

Hormonal imbalance
 Fibroids
 Uterine cancer


Treatment of primary and secondary
amenorrhea
Adjunctive and palliative treatment of some
cancers and endometriosis
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14
Progestins: Indications (cont’d)



Alone or in combination with estrogens to
prevent conception
Prevention of threatened miscarriage
Alleviation of PMS symptoms
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15
Progestins: Indications (cont’d)

megestrol (Megace)



Adjunct therapy for treatment of breast and
endometrial cancers
Management of anorexia, cachexia, or unexplained
weight loss in AIDS patients
To stimulate appetite and promote weight gain in
cancer patients
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16
Progestins: Adverse Effects






Liver dysfunction—cholestatic jaundice
Thrombophlebitis, thromboembolic disorders,
such as PE
Nausea, vomiting
Amenorrhea, spotting
Edema, weight gain or loss
Others
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17
Contraceptive Drugs


Medications used to prevent pregnancy
Oral medications

Monophasic, biphasic, and triphasic forms
• Triphasic form most closely duplicates the normal hormonal
levels of the female cycle


Newer extended-cycle products
Most contain estrogen-progestin combinations
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18
Contraceptive Drugs (cont’d)

Other contraceptive forms available

Long-acting injectable form of medroxyprogesterone
(Depo-Provera)
 Transdermal contraceptive patch
 Intravaginal contraceptive ring
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Contraceptive Drugs:
Mechanism of Action

Prevent ovulation by inhibiting the release of
gonadotropins and increasing uterine mucous
viscosity, resulting in:


Decreased sperm movement and fertilization of the
ovum
Possible inhibition of implantation of a fertilized egg
(zygote)
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Contraceptive Drugs:
Other Drug Effects



Improve menstrual cycle regularity
Decrease blood loss during menstruation
Decrease incidence of functional ovarian cysts
and ectopic pregnancies
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21
Contraceptive Drugs: Indications


Primarily used to prevent pregnancy
Other uses:

Treatment of endometriosis and hypermenorrhea
 Production of cyclic withdrawal bleeding
 Postcoital emergency contraception
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Contraceptive Drugs:
Adverse Effects

Drawbacks to the use of these drugs include:

Hypertension
 Thromboembolism, possible PE, MI, stroke
 Alterations in lipid and carbohydrate metabolism
 Increases in serum hormone concentrations

These effects are caused by the estrogen
component
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23
Contraceptive Drugs:
Adverse Effects (cont’d)

May also cause:

Edema, dizziness, headache, depression, nausea,
vomiting, diarrhea, increased appetite, increased
weight, breast changes, many others
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Contraceptive Drugs:
Interactions

Drugs that decrease effectiveness of oral
contraceptive drugs

Antibiotics
 Barbiturates
 Isoniazid
 Rifampin
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Contraceptive Drugs:
Interactions (cont’d)

Drugs that may have reduced effectiveness if
given with oral contraceptives

Beta blockers, warfarin, tricyclic antidepressants,
vitamins, hypnotics, anticonvulsants, theophylline,
and antidiabetic drugs
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Osteoporosis




Low bone mass
Increased risk of fractures
Primarily affects women
20% with this condition are men
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Osteoporosis: Risk Factors








Caucasian/Asian descent
Slender body build
Early estrogen deficiency
Smoking
Alcohol consumption
Low-calcium diet
Sedentary lifestyle
Family history
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Drug Therapy for Prevention of
Osteoporosis


Calcium supplements and vitamin D may be
recommended for women at high risk for
osteoporosis
Current recommendations are that women,
especially those older than age 60, consider
taking calcium and vitamin D supplements for
bone health
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Classroom Response Question
While taking a history of a 68-year-old female patient who
is receiving estrogen therapy as part of palliative treatment
for advanced breast cancer, which assessment finding
would be of most concern to the nurse?
A. The patient is on transdermal opioids for cancer pain.
B. The patient smokes 1 pack of cigarettes a day.
C. The patient drinks a glass of wine one evening a week.
D. The patient has a history of osteoporosis.
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Drug Therapy for
Osteoporosis

Bisphosphonates


Selective estrogen receptor modifiers (SERMs)



alendronate (Fosamax), ibandronate (Boniva),
risedronate (Actonel), zoledronic acid (Reclast)
raloxifene (Evista)
tamoxifen (Nolvadex)
Hormones



calcitonin (Calcimar)
teriparatide (Forteo)
denosumab (Prolia)
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Drug Therapy for
Osteoporosis (cont’d)

Bisphosphonates


Work by inhibiting osteoclast-mediated bone
resorption, thus preventing bone loss
SERMs

Stimulate estrogen receptors on bone and increase
bone density
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Drug Therapy for
Osteoporosis (cont’d)

calcitonin (Calcimar)


Directly inhibits osteoclastic bone resorption
teriparatide (Forteo)

Only drug that stimulates bone formation
 Derivative of parathyroid hormone
 Action similar to natural parathyroid hormone
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Drug Therapy for
Osteoporosis (cont’d)

denosumab (Prolia)


Monoclonal antibody that blocks osteoclast
activation, thereby preventing bone resorption
It is given as a subcutaneous injection once every 6
months along with daily calcium and vitamin D
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Drug Therapy for Osteoporosis:
Indications

Bisphosphonates


Both prevention and treatment of osteoporosis
Bisphosphonates also used for glucocorticoidinduced osteoporosis and Paget’s disease
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Drug Therapy for Osteoporosis:
Indications (cont’d)

calcitonin (Calcimar)



raloxifene (Evista)


Treatment of osteoporosis
Nasal spray (Miacalcin) most commonly used
Prevention of postmenopausal osteoporosis
teriparatide (Forteo)

Treatment for those with highest risk of fracture (prior
history of fractures)
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Drug Therapy for Osteoporosis:
Adverse Effects

SERMs

Hot flashes, leg cramps
 Increased risk of venous thromboembolism
 Teratogenic
 Leukopenia
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Drug Therapy for Osteoporosis
Adverse Effects (cont’d)

Bisphosphonates

Headache, GI upset, joint pain
 Risk of esophageal burns if medication lodges in
esophagus before reaching the stomach
 Risk of osteonecrosis of the jaw
 Possible severe (incapacitating) bone, joint, or
muscle pain
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Drug Therapy for Osteoporosis
Adverse Effects (cont’d)

calcitonin


teriparatide


Flushing of the face, nausea, diarrhea, and reduced
appetite
Chest pain, dizziness, hypercalcemia, nausea, and
arthralgia
denosumab

Infections
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39
Classroom Response Question
A 60-year-old woman is taking a bisphosphonate. She calls
the clinic and tells the nurse that her stomach has been
bothering her and wants to know what she should do. The
nurse will instruct her to:
A. take this medication with milk.
B. take this medication with breakfast.
C. remain upright in a sitting position for at least 10
minutes after taking this medication.
D. stop the medication and to come in for an evaluation.
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Fertility Drugs

Various medical techniques used to treat
infertility

Includes in vitro fertilization and medication therapy
(ovulation stimulation)
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Fertility Drugs (cont’d)

clomiphene (Clomid, Serophene)

Nonsteroidal ovulation stimulant
 Blocks estrogen receptors in the uterus and brain,
resulting in a false signal of low estrogen levels
 Increases production of Gn-RH, FSH, and LH
 As a result, maturation of ovarian follicles is
stimulated, leading to ovulation and increased
chance of conception
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Fertility Drugs (cont’d)

menotropins (Pergonal)

Standardized mixture of FSH and LH
 Stimulates development of ovarian follicles, leading
to ovulation
 May also be given to men to stimulate
spermatogenesis
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43
Fertility Drugs (cont’d)

chorionic gonadotropin alfa (Ovidrel)

Recombinant form of human chorionic gonadotropin
 Causes rupture and ovulation of mature ovarian
follicles, and maintenance of corpus luteum
 Used to stimulate ovulation
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44
Fertility Drugs: Indications


Used primarily to induce ovulation in
anovulatory patients
Also may be used to promote spermatogenesis
in infertile men
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45
Fertility Drugs: Adverse Effects




Tachycardia, hypovolemia, DVT
Dizziness, headache, flushing, depression,
restlessness, anxiety, nervousness, fatigue
Nausea, bloating, constipation, vomiting,
anorexia
Urticaria, ovarian hyperstimulation, multiple
pregnancy, blurred vision, diplopia,
photosensitivity, breast pain
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46
Uterine Stimulants


Medications used to alter uterine contractions
Used to:

Promote labor
 Prevent the start or progression of labor
 Postpartum use: reduce the risk of postpartum
hemorrhage
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47
Uterine Stimulants (cont’d)

Also called oxytocics

Oxytocin (hormonal drug)
 Prostaglandins
 Ergot derivatives
 Progesterone antagonist mifepristone (RU-486)
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48
Uterine Stimulants (cont’d)

oxytocin (Pitocin)—synthetic form


Used to induce labor at or near full-term gestation,
and to enhance labor when contractions are weak
and ineffective
Other uses



Prevent or control postpartum uterine bleeding
Complete an incomplete abortion (after miscarriage)
Promote milk ejection during lactation
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49
Uterine Stimulants (cont’d)

Prostaglandins

Natural hormones
 Cause potent contraction of myometrium, smooth
muscle fibers of the uterus
 Used to induce labor by softening the cervix and
enhancing uterine muscle tone
 dinoprostone (Prostin E3) and misoprostol (Cytotec)
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50
Uterine Stimulants (cont’d)

Ergot alkaloids

Increase force and frequency of uterine contractions
 Used after delivery of the infant and placenta to
prevent postpartum uterine atony and hemorrhage
 methylergonovine (Methergine)
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51
Uterine Stimulants (cont’d)

Progesterone antagonist



mifepristone (Mifeprex)
Stimulates uterine contractions to induce abortion
Given with a prostaglandin drug for elective abortions
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52
Uterine Stimulants:
Adverse Effects





Hypotension or hypertension, chest pain
Headache, dizziness, fainting
Nausea, vomiting, diarrhea
Vaginitis, vaginal pain, cramping
Leg cramps, joint swelling, chills, fever,
weakness, blurred vision
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53
Classroom Response Question
A woman in labor is on an oxytocin infusion. The nurse notes that her
contractions are close to 100 seconds apart and are lasting 1.25
seconds. The mother’s blood pressure has increased to 130/98, and
the fetal heart rate decreases during the contractions. The woman
states, “Wow, this medicine is sure hurrying things along!” The nurse’s
next action(s) will be to:
A. continue to monitor the labor, which is progressing nicely.
B. offer comfort measures during the contractions.
C. stop the infusion, administer oxygen, have her lie on her left side,
and notify the physician immediately.
D. take the patient to the delivery area because delivery is imminent.
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54
Uterine Relaxants:
Tocolytics


Used to stop labor that begins before term to
prevent premature birth
Generally used after the 20th week of gestation
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55
Uterine Relaxants:
Tocolytics (cont’d)


Uterine contractions that occur between the
20th and 37th weeks of gestation are
considered premature labor
Nonpharmacologic measures

Bed rest, sedation, hydration
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56
Uterine Relaxants

indomethacin



Nonsteroidal antiinflammatory agent
Inhibits prostaglandin activity
nifedipine


Calcium channel blocker
Inhibits myometrial activity by blocking calcium influx
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57
Uterine Relaxants (cont’d)

When indomethacin and nifedipine are
ineffective and delivery is proceeding,
corticosteroids (betamethasone or
dexamethasone) are administered to the mother
to promote lung maturity in the fetus between 24
to 34 weeks of gestation.
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58
Herbal Products: Soy



Relief of menopausal symptoms, osteoporosis
prevention
Estrasorb, applied as a lotion
Adverse Effects

Nausea
 Diarrhea
 Abdominal pain
 Estrasorb remains on skin for 8 hours
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59
Nursing Implications




Assess baseline vital signs, weight, blood
glucose levels, renal and liver function studies
Assess whether the patient smokes
Assess history and medication history
Assess contraindications, including potential
pregnancy
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60
Classroom Response Question
A woman has not taken her oral contraceptive since
Monday. It is now Wednesday morning. What should she
do now to prevent pregnancy?
A. Take the two missing doses as soon as possible.
B. Continue the drug as if no doses were missed.
C. Start over with a new monthly pack of oral
contraceptives.
D. Resume the drug but also use a second form of birth
control.
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61
Nursing Implications (cont’d)


Before giving any uterine stimulants, assess the
mother’s vital signs and fetal heart rate
Uterine relaxants are used when premature
labor occurs between the 20th and 37th weeks
of gestation
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62
Nursing Implications (cont’d)

For bisphosphonates, ensure that patients have
no esophageal abnormalities and can remain
upright or in a sitting position for
30 minutes after the dose
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63
Nursing Implications (cont’d)

Estrogens and progestins

Take the smallest dose needed
 Give IM doses deep in large muscle masses, and
rotate sites
 Give oral doses with meals to reduce GI problems
 Teach patients about correct self-administration and
what to do if a dose is missed
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64
Nursing Implications (cont’d)

Estrogens and progestins (cont’d)

Increased susceptibility to sunburn may occur—
advise patients to wear sunscreen or avoid sunlight
 Instruct patients to report weight gain
 Advise patients to complete annual follow-up
examinations, including PAP smear and breast
examination
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65
Nursing Implications (cont’d)


Follow specific administration guidelines
carefully for administration of uterine relaxants
or stimulants
Monitor patient’s vital signs and fetal condition
during therapy
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66
Nursing Implications (cont’d)


Instruct patients taking fertility drugs to take the
medication as ordered
Advise patients to keep a journal while on
fertility drugs
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67
Nursing Implications (cont’d)

Bisphosphonates


Instruct patients to take medication upon rising in the
morning, with a full glass of water, and
30 minutes before eating
Emphasize that patients should sit upright for at least
30 minutes after taking the medication
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68
Nursing Implications (cont’d)

SERMs

Instruct patients that the medication will need to be
discontinued 72 hours before and during any
prolonged immobility (such as surgery or a long trip)
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69
Nursing Implications (cont’d)


Monitor for therapeutic responses
Monitor for adverse effects
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